Care Plan: K.K.
Male, age unknown
Height: 154 cm
Weight: 115 kg
Total cholesterol: 396
Triglycerides: 300
Hemoglobin A1C: 14.5
Current Medical Diagnoses: Obesity, DM II, tobacco abuse, rosacea, osteoarthritis
Social History: Denies drug use. Social alcohol. Manages herd of ruminants. Hobbies include woodworking and toy making (toxic paint exposure). In the past has had extensive exposure to soot and ash in the performance of job duties. Married, lives with wife and a number of unrelated short people. No stairs in home. Patient states his diet consists mostly of cookies and warm milk.
Nursing Diagnoses:
Goals for This Hospitalization:
Notes from Other Disciplines:
PT: Patient has belly like bowl full of jelly. Good standing balance, walked 300’ unassisted. Discharged from PT; please reconsult if necessary.
OT: Patient performs all ADLs without assistance. Discharged from OT.
Psychiatry consult service: Patient shows tendency to laugh inappropriately, wink and place finger on the side of his nose. Consider dementia, chronic microvascular changes in DD.
Expected Discharge Dispo: Discharge to home no later than a.m. of 12/24.
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